=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376928481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CUCAMONGA PEAK ENDODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2015
-----------------------------------------------------
Last Update Date | 07/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11438 KENYON WAY # 3-C
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91701-9230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-945-5262
-----------------------------------------------------
Fax | 909-945-5223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11438 KENYON WAY # 3-C
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91701-9230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-945-5262
-----------------------------------------------------
Fax | 909-945-5223
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAEHOON LEE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 909-945-5262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 63274
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------